Joint Parliamentary Committee 24 May 2013 Sex Work Sector SWEAT South African Sex Work Program, 2012 – 2016 Leveraging a Public Health & Human Rights Approach for HIV and Sex Work programming in South Africa Joint Parliamentary Committee 24 May 2013 Sex Work Sector SWEAT

Overview Programme principles Programme aims, objectives & outcomes Activities Scale-up Monitoring & evaluation Timeframe Next steps

Sex workers & society Society usually views sex workers negatively (in addition to lower social position and power of women & minority groups) Moral judgment, criminalisation, stigma & discrimination Marginalisation, exclusion & disempowerment Generally speaking, society has a very negative attitude towards sex workers. This negative attitude is often in the context of the lower socioeconomic status of women and other minority groups. The experiences moral judgement, social stigma and discrimination results in marginalisation, social exlusion and disempowerment.

Sex work in South Africa Sex work is very common Yet, all aspects of sex work are ILLEGAL Contextual factors result in: Marginalisation Increased vulnerability to violence No access to legal recourse Discrimination prevents health & legal service access Disempowerment limits ability to negotiate condoms Unsafe working conditions & no workplace protections Sex work is common, it occurs in every village, town and city in South Africa Sex work takes place in a variety of settings: In both formal and informal settings, like: brothels, massage parlours, road side, in taverns, truck stops, hostels and others Sex work involves a diverse stakeholders: Sex workers, clients, sex worker emotional partners, business owners and intermediaries Sex work is ongoing despite ILLEGALITY of all aspects of sex work: Selling sex, purchasing sexual services, owning a facility that provides sexual services etc.

Sex work in South Africa Hostile environment Social exclusion & marginalisation Risk of arrest & extortion No access to legal recourse Disproportionately high risk for HIV infection Conditions favouring HIV transmission Unfavourable conditions for good health outcomes Violence & rights abuses Police harassment & violence Sexual & physical assault Poor understanding of rights No workplace protections Sex workers in South Africa live and work in hostile environments, endure high levels of human rights abuses and historically have not enjoyed the benefits of a responsive, non-discriminatory health system. These elements contribute to the disproportionately high risk for HIV infection among sex workers, and for the transmission of HIV among them and their clients and sexual partners. Additionally, limited access to enabling health environments prevent good health outcomes among sex workers living with HIV. Unresponsive health system No national govt. led SW programme Limited coverage of health services Limited prevention commodities Discrimination by health workers

Sex work & HIV in South Africa HIV prevalence among female sex workers 60% - versus 25% among women (15-49 yrs)1 Female sex workers 4 times more likely to be HIV infected compared to women (15 – 49 yrs)1 Estimated 20% of all new HIV infections occur among sex workers2 1. Baral et. al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis 2012. Lancet 12 (3099). 2. SACEMA. Modes of Transmission Study. Report. Stellenbosch. 2010

South Africa’s National Response

Programme Principles Sex workers are equal citizens and have families Sex workers’ rights and dignity must be respected Sex workers are not victims by virtue of being sex workers Sex work is a livelihood option Sex worker ownership: “nothing about, us without us” Evidence-informed response Interventions should not do harm Collective sex worker engagement, mobilisation and empowerment essential for success

Aims Increase coverage & access to comprehensive HIV, STI & TB services for SW, their partners and families Reduce violence and human rights abuses experienced by SW Create enabling health & related systems for the realisation of Constitutional rights

Objectives Reduce social & structural barriers to HIV, STI & TB prevention, care and impact Reduce sexual transmission of HIV among SW Sustain SW health and wellness Strengthen the health system Collect information & research to enable an effective HIV response

Expected outcomes Reduction in human rights violations experienced by SW SW-focused policy & programme inclusion across sectors Empowered & capacitated sex workers Established SW coalitions & networks Capacitated health & law enforcement workers Increased access to legal recourse for SW Progression towards the decriminalisation of SW Increased access to package of SW services Increased access to services for SW partners & clients Increased proportion of SW living with HIV on ART Appropriate SW programme performance management Improved commodity supply chain management Evidence on new HIV-related advances for SW

Ultimate impact Removal of structural barriers & legal reform to allow realisation of rights & effective responses Reduction in new HIV infections among SW and their partners Reduction in HIV and TB related deaths among SW High quality, efficient & responsive health system Evidence-informed policy & programming

NATIONAL SEX WORK PROGRAMME LOGIC MODEL

NSWP activities (1) Mobilisation & engagement Service provision HIV/STI/TB services SW needs assessment SRH services SW-led organisation establishment Psychosocial services Alcohol & drug support services SW capacity building Safe space establishment Access to justices Services to address exploitation Network establishment

NSWP activities (2) Communication Structural reform Sensitisation Health & rights Health systems & community strengthening Sensitisation Health workers Information Law enforcers Monitoring & Evaluation Advocacy Surveillance Human rights Research Access to justice Decriminalisation

Context 1: Hot Spot! Large population in relatively contained, urban area.

Context 2: Large population, rural or focussed on particular contextual element, mobile and tend to be reached only at work (truck stop, mine etc)

Context 3: General context: smaller population or unknown population size, generalised area, contextually varied

SERVICE PACKAGE MATRIX Context i Service delivery model ii Package of services iii Metropolitan area High concentration of SW Specialist sex worker clinics (NGO-govt. partnership) e.g. Essen St clinic extended hours established networks mobile services 1. Condoms & lubricant 2. PEP 3. STI/TB diagnosis & management 4. HIV, testing, treatment, care & support 5. Psychosocial services & risk reduction 6. Referral for substance abuse 7. Reproductive & sexual health 8. IEC materials 9. Safe spaces & peer-led mobilisation Sex worker ‘hot spots’ Sex-worker focused services (NGO or govt. provided) e.g., truck stops Includes sex worker clients Includes mobile services 1. Services described above (1 – 9) 2. Services for sex worker partners (1 -5, 9) 3. Mobile services ( 1 – 4, 9) Other areas HTA clinics Sex-worker friendly services Outreach work & primary health care package, provided in a sensitised manner i. Context assessed through location mapping & needs assessment, defined by SW concentration ii. Peer led outreach, education, linkage to services & support provided in all contexts

Service delivery 1: Hot Spot!

Service delivery 2: Large population, rural or focussed on particular contextual element, mobile and tend to be reached only at work (truck stop, mine etc)

Service delivery 3: General context: smaller population or unknown population size, generalised area, contextually varied

Peer-led activities Sex worker peers understand contexts & complexities of industry Sharing of knowledge, skills & building capacity between peers Key to success of sex work programmes in India Collective mobilisation and empowerment can lead to change Peer progression model – career pathing of SW peers Approach builds on Quality Assurance Standards for Peer Education & Outreach Workers for High Risk Vulnerable populations in South Africa

What is the innovation? Evidence informed programming Mobilisation - Sex worker targeted (not accidental, hidden or unknown) Fit for purpose=fit for context Sex worker peer educators Sex worker community strengthening Up-scaling successful interventions Health worker sensitisation Advocacy / human rights approach Co-ordinated

Monitoring & Evaluation Under development, based on logic model Inputs into national M&E framework National Level (SANAC) Impact & outcome indicators Bio-behavioural surveys required Audits of specific programme elements Local level (implementers) Process indicators Include quality indicators Include SW satisfaction surveys

TIME FRAME:

Sex work programme next steps Refine implementation model & cost SW ratification & input on programme Formalise role of the SW TWG Initiate capacity building of health care workers & organisations ahead of scale-up

Contact us sallys@sweat.org.za 021 4487875 Sex Worker Help line: 0800 606060 Or please-call-me 071357 7632

PARTNERSHIPS FOR SW INTERVENTIONS